The occurrence of a stroke is a sudden, dramatic, and at times irreversible reminder
that life is finite, a fact which in our culture is subject to insistent denial.
This illness often precipitates an array of behavioral reactions designed to
protect the individual from the distress and anxiety that would otherwise arise
in connection with the realization of serious disability, helplessness,
dependency, and, in the case of survival, the close call with death.

Because of an age incidence predominantly involving people in the sixth decade of life and
later and the frequent occurrence of severe and enduring neurological deficits,
the stroke tends to be a disorganizing experience for the patient and his
family. A variety of defensive operations may become manifest as the patient
moves from the period of initial crisis, through the convalescent stage with
recovery or stabilization of deficits, to the rehabilitation period where
efforts are directed to the restoration or improvement of function.

The more important reactions occurring following strokes will be briefly considered in an
effort to better orient the physician and other concerned parties to their
meaning and importance. The main categories of response include the
idiosyncratic defensive attitudes characteristic of the individual and evoked by
the initial impact of the illness, the development of depressive and paranoid
reactions, and the problems associated with denial of illness and anosognosia
(the latter term refers to unawareness of illness or deficit associated with
brain damage).

The initial subjective reactions of the patient are organized on the basis of two dynamic
principles. He is at one and the same time attempting to define for himself the
nature of what it is that is happening to him and he is attempting to do it in a
way that will do the least damage to his sense of physical intactness, his
personal value system, and his sense of social relatedness. In most instances,
in situations where the patient is faced with the stress of an illness that may
be the harbinger of disability, dependency, or even death, these initial
defensive operations often take the form, implicitly or explicitly, of
minimizing the experience.

Under these circumstances rationalizations emerge, linking the initial symptoms to earlier
and more benign forms of illness or disability. Activity is engaged in designed
to further the illusion that nothing serious has occurred. One patient with an
incipient hemiplegia continued to drive a cab. Another bought a cane in order to
walk to the hospital. At the time that President Eisenhower suffered a transient
and mild cerebrovascular accident, several patients with more massive brain
damage and severe hemiplegia euphemistically referred to their illness as
“Eisenhower s disease.” Stoical attitudes often betray an underlying sense of
personal inviolability.

Depressive Reactions

The term depression is used here to encompass reactions varying from mild and transient
states of unhappiness to full-blown neurotic or psychotic states. The seriousness of the illness and the frequent
residue of paralysis, with or without speech disturbances, almost inevitably
precipitate an initial depressive response. In many ways this resembles the
grief associated with the loss of a love object. Analogously, the transformation
and dissipation of this feeling is a function of time, degree of recovery, and,
in favorable circumstances, the possibilities of favorable restitution of the
life situation.

This type of reaction closely parallels the progress of the disease. The feelings are those
of unhappiness and resignation but characteristically lack the self-deprecation,
the guilt, the intrusions of concepts of sin and punishment, and the intense
projection of hopelessness that betray the underpinnings of the more serious
forms of depression. In the neurotic depression, the patient is responding to
the symbolic meaning of the stroke rather than to the actual deficit or material
impairment in his life situation.

In one patient, a middle-aged woman, separated and living alone, the occurrence of a
stroke resulted in the resurgence of guilt and self-deprecation based on her
concern that the present illness was the result of a syphilitic infection
innocently acquired some 30 years before. The stroke itself was simply a vehicle
for the symbolic expression of unresolved guilt and anxiety in connection with
her earlier marriage and subsequent withdrawal from heterosexual contacts.

In the psychotic depression, the history of antecedent episodes as well as the
psychotic proportions of the symptomatology establish the diagnosis.

The management of neurotic and psychotic depressions generally requires the services
of a psychiatrist to explore, in the case of the former, the way in which the
current episode is linked to the patient’s past and, in the latter, to have
recourse to the various somatic therapies.

The management of what might be called the more normal grief reaction devolves upon
the members of the rehabilitation team and is a function of their degree of
success in nurturing the motivational potential of the patient. This reaction is
characterized by what in effect is a period of mourning for the functional loss
of the involved limb. The patient reflects a mood of sadness which under these
circumstances is genuine, appropriate, and inevitable. The response is
proportional to the severity of the enduring physical deficit. Relief comes only
when new avenues of functional usefulness and mastery are established.

This is highlighted in the case of the aphasic patient whose sense of self-esteem has
been closely linked with intellectual achievement and verbal communication. In
one such patient it was possible to tap latent creative talents so that
effective self-expression was achieved through painting.

Paranoid Responses

A not infrequent response masking or perhaps preventing an underlying depression is
that of negativism, belligerence, irritability, and the general tendency to
project blame and responsibility externally. Personnel in attendance are often
the chief victims of what in essence is u kind of paranoid barrage arising as a
consequence of the patient’s inability to come to grips with the effects of his
illness. In the more elderly patient with associated features of cerebral
arteriosclerosis this may take the form of an organized paranoid delusional
system. The following is an example taken from an interview with a 75-year-old
woman with a left hemiparesis:

I can go in the washroom but they won’t let me, these colored girls'. They’re terrible. It’s
not the hospital it used to be. They think they can rule the hospital. Oh no,
not yet! There’s too much girl-friend and boy-friend business going on. They
brought all of Harlem here. The hospital isn’t clean the way it used to be. .

In this instance the stroke, in conjunction with generalized cerebro-arteriosclerosis,
lowered the cortical controls touching off earlier sexual conflicts. These in
turn were handled through the mechanism of projection resulting in feelings of
persecution at the hands of the Negro personnel in the ward.

Denial and Anosognosia

Certain problems arise in connection with the attitude of stroke patients toward a
residual hemiplegia. Babinski in 1918 noted the tendency of a stroke patient to
remain unaware of an existing paralysis and to maintain this unawareness despite
efforts to call it to his attention. In the intervening time a number of
neurologically oriented explanations have been preferred, based on damage to
specific underlying neural structures, e.g., parietal lobe with resultant
impaired sensory integration (an example is Denny-Brown’s concept that
unawareness of a hemiplegic limb is the result of the defective perception of
the spatial aspects of all forms of sensation), and damage to structures
responsible for the intactness of the body image (e.g., the work of Head and
Holmes linking parietal lobe damage to disturbance in the three-dimensional
representation in the mind of the “body scheme”).

More recently Weinstein and Kahn in a series of papers and a monograph [Weinstein,
Edwin A., M.D., and Kahn, Robert L., Ph.D., “Denial of Illness,” Springfield,
111.: Charles C. Thomas, 1955] developed a radically different point of view.
They explained the behavior of the patient in terms of characteristic patterns
of defensive operations intrinsically related to the premorbid personality but
now becoming manifest under altered states of brain function. Hence the
behavior, while expressing characteristic attitudes, does so by means of
different symbolic elements because of the factor of cerebral dysfunction.

The patient whose premorbid personality revealed denial patterns in relation to illness
would tend to show an anosognosic response. Those who tended to withdraw in
relation to stress might react with apathy and mutism. Such phenomena as
paraphasia, confabulation, disorientation for time, place, or person, and
reduplication were explained on the basis of idiosyncratic motivational needs of
the individual patient. The authors felt that in one way or another the behavior
expresses the effort to identify with those values which, in terms of the
patient’s past experience, represent health and continued relatedness with his
own cultural milieu.

This contribution represented a significant step forward in integrating dynamic
personality concepts with the neurological point of view concerning the behavior
of brain damaged patients.

The final behavioral response, the one of concern to the rehabilitation team, is the
resultant of all the factors influencing the patient’s capacity to perform, as
well as his motivation to perform. In the presence of local brain dysfunction
certain specific sensory and motor effects occur which influence the capacity of
the patient to respond appropriately. If the stroke involves diffuse brain
dysfunction, we meet with profound difficulties in abstract thought, an
occurrence which radically alters the patient’s response capacity.

True anosognosia is associated with the occurrence of a local deficit such as a
hemiplegia in conjunction with diffuse brain damage and difficulty in engaging
in abstract thought. This difficulty prevents the patient from adequately
conceptualizing and realistically integrating the nature of his illness and the
residual motor deficit. Motivation, with its roots in the premorbid personality
and current life situation, interacts with capacity and the final behavioral
response is determined by this interaction. When the impaired capacity dominates
the situation an anosognosic response occurs.

With less impairment, motivational patterns emerge more clearly, and these move either in
the direction of denial of illness or toward a more normally integrated
response.

The Psychiatrist and the Stroke Patient

The role of the psychiatrist will, of course, vary considerably in relation to individual
patients as well as the setting in which treatment and rehabilitation is carried
out. In a general hospital setting one of the initial tasks is to orient the
house staff to the meaning of a stroke to a patient in the fifth decade of life
or older.

The age difference between the young physician and the older patient, as well as the
former’s more active orientation to more esoteric problems, makes for a certain
emotional distance and perfunctoriness in the management of the stroke
patient—both of which are not only contraindicated but unnecessary.

When the physician becomes patient-oriented rather than organ pathology-oriented, he
becomes sensitive and responsive to the drama that is set into motion by the
occurrence of a stroke. The sudden disruptive effect upon the life situation of
the patient, the many anxieties relating to death and disability, the occurrence
of the illness at a time in life when physical and personal resources may be on
the wane, .taxes the adaptive capacities to the extreme and creates the need for
new sources of support, reassurance, and guidance.

There are a number of problems occurring during the period of convalescence and
rehabilitation as well as following the discharge of the patient that may
require the special services of the psychiatrist. These involve the management
of depressive reactions, the occasional psychotic episodes following the stroke,
and problems of disposition when severe brain syndromes are present. The first
two involve the use of psychotherapy and, when indicated, antidepressive
medication and tranquilizers. Severe brain syndromes are best managed within an
institutional setting.

In most instances the psychiatrist can function as a useful member of the rehabilitation
team in orienting the other members to the defensive operations (e.g., denial,
withdrawal, projection) of the patient, the specific areas of vulnerability in
task performances (e.g., the intellectual residue of brain damage in the form of
limited attention span, defective carry-over, and perceptual impairment based on
the existence of sensory deficits), the meaning of success and failure in terms
of the patient’s motivation (e.g., to what extent is the task meaningful and
important to the patient), and the influence of the patient’s total life
situation and personality on his behavior in the rehabilitation setting.

The problems arising following discharge involving family, work, and social relationships may
also require specific psychotherapeutic intervention.